Balance dysfunction and vestibular conditions are major problems requiring significant resources. There is significant national and international variation in management pathways for such patients.

This paper outlines a collaborative project run by the ENT department and two vestibular rehabilitation trained physiotherapists to establish a clinic to manage patients referred to ENT with vestibular and/or balance complaints. As part of a six-month pilot, two physiotherapy-led balance clinics were provided per week.

A total of 159 new patients were seen, with only 15 needing ENT consultant input. This led to the successful creation of substantive posts; the clinic has seen 698 patients in its first two years.

Patient outcomes and experience have been positive, and accompanied by reduced waiting and in-service times. The authors discuss some of the pitfalls, challenges and opportunities of developing this type of clinic.

To examine the newly established role of a primary contact physiotherapist in an ENT clinic, in an Australian cohort and context, over two phases of development.

A retrospective cohort study was conducted with data collected from a medical record audit. Over the study duration, the primary contact physiotherapist completed initial appointments with patients; follow-up appointments were subsequently conducted by medical staff.

There was a 46 per cent reduction in patients with suggested vestibulopathy requiring an ENT medical review. This reduction could hypothetically increase to 71 per cent with follow-up primary contact physiotherapist appointments. Improvements in the service delivery model and a primary contact physiotherapist arranging diagnostic assessments could improve waitlist times and facilitate better utilisation of medical staff time.

The primary contact physiotherapist can help in the management of patients with suspected vestibulopathy on an ENT waitlist. This is achieved through: a reduction of patients requiring ENT review, improvements to waitlist time and improved utilisation of medical specialists’ time.

Persistent postural-perceptual dizziness classifies patients with chronic dizziness, often triggered by an acute episode of vestibular dysfunction or threat to balance. Unsteadiness and spatial disorientation vary in intensity but persist for over three months, exacerbated by complex visual environments.

Literature suggests diagnosis relies on a clinical history of persistent subjective dizziness and normal vestibular and neurological examination findings. Behavioural diagnostic biomarkers have been proposed, to facilitate diagnosis.

Research has focused on understanding the neural mechanisms that underpin this perceptual disorder, with imaging data supporting altered connectivity between neural brain networks that process vision, motion and emotion. Behavioural research identified the perceptual and motor responses to a heightened perception of imbalance.

Management utilises head and body motion detection, and downregulation of visual motion excitability, reducing postural hypervigilance and anxiety. Combinations of physical and cognitive therapies, with antidepressant medications, help if the condition is associated with mood disorder.

Driving capacity is affected by vestibular disorders and the medications used to treat them. Driving is not considered during medical consultations, with 92 per cent of patients attending a centre for dizziness not discussing it with the doctor.

To investigate if medical record prompts facilitate dizziness and driving conversations in ENT balance clinics.

A questionnaire was designed to reflect the current standards of practice and advice given regarding driving and dizziness during balance clinic consultations.

Medical record prompts facilitated the improved frequency and recording of shared decision-making conversations about driving and dizziness in 98 per cent of consultations.

This study highlights the benefits of medical record prompts for documented and accurate shared decision-making conversations surrounding dizziness, vertigo, vestibular conditions and driving. This potentially improves safety for all road users, and protects the patient and clinician in the event of road traffic accidents and medico-legal investigations.

There have been many studies linking falls and benign paroxysmal positional vertigo. This article collates those studies, and demonstrates how a community falls service fast-tracked patients with benign paroxysmal positional vertigo by implementing validated screening tools and recognised guidance.

This study aimed to explore whether routine screening of referrals to a community falls service can identify those with benign paroxysmal positional vertigo, for fast-tracked management.

Patients referred to a community falls service were screened for possible benign paroxysmal positional vertigo using the Dizziness Handicap Inventory, and triaged to a physiotherapy-led falls and benign paroxysmal positional vertigo assessment service.

Twenty-five per cent of patients were fast-tracked to a falls and benign paroxysmal positional vertigo assessment service for management. The community falls service waiting list reduced by 25 per cent.

The data support incorporating assessment and treatment of benign paroxysmal positional vertigo into routine practice within all falls services.

Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic.

Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine.

A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging.

This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.

There is a high prevalence of dizziness, vertigo and balance symptoms in the general population. Symptoms can be generated by many inner-ear vestibular disorders and there are several diagnostic tests available that can help identify the site of the vestibular lesion. There is little consensus on what diagnostic tests are appropriate, with diagnostics either not completed or minimally performed, leading to missed diagnosis, unsatisfactory results for patients and costs to healthcare systems.

This study explored the literature for different neuro-vestibular diagnostic tests not currently considered in the traditional standard vestibular test battery, and examined how they fit effectively into a patient care pathway to help quickly and succinctly identify vestibular function.

A vestibular patient care pathway is presented for acute and subacute presentation of vestibular disorders.

An accurate diagnosis following a rigorous anamnesis and vestibular testing is paramount for successful management and favourable outcomes.

This study aimed to evaluate the effectiveness of tai chi on balance in patients with improved but persistent dizziness and imbalance following completion of traditional vestibular rehabilitation therapy.

Patients who completed vestibular rehabilitation therapy with persistent imbalance were prospectively enrolled in a tai chi programme comprising eight weekly classes. Balance was assessed before the first and after the eighth session using the Dynamic Gait Index, Activities-Specific Balance Confidence scale and Dizziness Handicap Inventory.

A total of 37 participants (34 females, 3 males) completed the programme with balance testing. Mean age was 76.8 years (range, 56–91 years). Mean Dynamic Gait Index significantly increased after completion of tai chi (p < 0.00001). Mean Activities-Specific Balance Confidence scale score increased from 63.6 to 67.9 per cent (p = 0.046). A subset (n = 18) of patients completed a Dizziness Handicap Inventory without significant post-therapeutic change (p = 0.62). Most (36 of 37; 97.3 per cent) patients demonstrated post-therapy improvement on one or more assessments.

Tai chi is a viable adjunct to improve balance in patients who complete a vestibular rehabilitation therapy programme.

This paper reports our experience in managing dizzy patients remotely during the coronavirus disease 2019 pandemic, and explored its safety as an alternative to face-to-face consultations.

Dizzy patients referred by their general practitioner were contacted to answer a validated questionnaire. Clinicians recorded the time needed for consultations, and the diagnosis at each of the following assessment stages: after review of the electronic general practitioner letter; following completion of the questionnaire; following the telephone consultation; and/or at follow up. Patients were telephoned no earlier than three months later to determine satisfaction with the service and symptom resolution. Electronic patient records were checked for presentation to hospital because of dizziness.

Seventy patients had telephone consultations. None presented to the emergency department or were admitted. The majority of consultations took 15–30 minutes. The most diagnosed condition was benign positional paroxysmal vertigo. Seventy-nine per cent of patients were satisfied with the service. The questionnaire and telephone consultations demonstrated the greatest diagnosis agreement (κ = 0.40).

Validated questionnaire and telephone consultations are a safe alternative to face-to-face consultations. Our patient referral pathway has now changed to include elements of the questionnaire.

Patients with essential tremor exhibit heterogeneous cognitive functioning. Although the majority of patients fall under the broad classification of cognitively “normal,” essential tremor is associated with increased risk for mild cognitive impairment and dementia. It is possible that patterns of cognitive performance within the wide range of normal functioning have predictive utility for mild cognitive impairment or dementia. These cross-sectional analyses sought to determine whether cognitive patterns, or “clusters,” could be identified among individuals with essential tremor diagnosed as cognitively normal. We also determined whether such clusters, if identified, were associated with demographic or clinical characteristics of patients.

Elderly subjects with essential tremor (age >55 years) underwent comprehensive neuropsychological testing. Domain means (memory, executive function, attention, visuospatial abilities, and language) from 148 individuals diagnosed as cognitively normal were partitioned using k-means cluster analysis. Individuals in each cluster were compared according to cognitive functioning (domain means and test scores), demographic factors, and clinical variables.

There were three clusters. Cluster 1 (n = 64) was characterized by comparatively low memory scores (p < .001), Cluster 2 (n = 39) had relatively low attention and visuospatial scores (p < .001), and Cluster 3 (n = 45) exhibited consistently high performance across all domains. Cluster 1 had lower Montreal Cognitive Assessment scores and reported more prescription medication use and lower balance confidence.

Three patterns of cognitive functioning within the normal range were evident and tracked with certain clinical features. Future work will examine the extent to which such patterns predict conversion to mild cognitive impairment and/or dementia.

To report the introduction and impact of non-medical prescribing, initiated to improve patient pathways for those presenting with dizziness and balance disorders.

The Southport and Ormskirk physiotherapy-led vestibular clinic sees and treats all patients with dizziness and balance disorders referred to the ENT department. Letters are triaged by an audiologist, who also performs an otological examination and hearing test; this is followed by an assessment with the independent prescriber physiotherapist. An ENT consultant is nearby if joint consultation is needed. Diagnoses, treatments and patient satisfaction were studied, with an analysis of the impact of medication management (stopping or starting medicines) on patients and service.

In 12 months, 413 new patients with dizziness and balance disorders had appointments. The most common diagnoses were benign paroxysmal positional vertigo and vestibular migraine. Eighty-four per cent of patients required self-management strategies, 50 per cent exercise therapy, 48 per cent medication management and 24 per cent a particle repositioning manoeuvre. Patient satisfaction was high (99 per cent).

Having an independent prescriber physiotherapist leading the balance clinic has reduced the number of hospital visits and onward referrals. Nearly half of all patients required medication management as part of their dizziness or balance treatment.

To determine whether demographic characteristics or balance examination findings can predict the adherence of older people with instability to a vestibular rehabilitation programme.

A prospective case–control study was conducted of 120 patients aged 65 years or more (mean age, 77.3 ± 6.33 years). Two groups were classified according to patients’ adherence with the follow-up post-rehabilitation protocol. Analysed variables included: age, sex, body mass index, Timed Up and Go test findings, computerised dynamic posturography, Dizziness Handicap Inventory scores and Short Falls Efficacy Scale – International questionnaire results, number of falls, and type of vestibular rehabilitation.

Two groups were established: adherents (99 individuals) and non-adherents (21 individuals). There were differences between the groups regarding: sex (female-to-male ratio of 4.8:1 in adherents and 1.63:1 in non-adherents), age (higher in non-adherents) and voluntary movement posturographic test results (non-adherents had poorer scores).

The patients most likely to abandon a vestibular rehabilitation programme are very elderly males with low scores for centre of gravity balancing and limits of stability.

Postural sway can be assessed clinically using the Romberg test, or quantified using dynamic posturography. We assessed the potential use of a novel iPhone application as a method of quantifying sway.

Fifty healthy volunteers performed the Romberg and tandem Romberg tests on a hard floor and on foam in soundproofed and normal clinic rooms. Postural sway was recorded using the D+R Balance application and data were compared using paired t-tests.

Significantly more postural sway was noted in participants when standing with their eyes closed and feet in the ‘tandem’ position vs feet together; standing with their eyes closed on foam vs on the floor; and standing with their eyes closed on foam with feet in the tandem position vs on the floor with feet together.

This feasibility study suggests that the iPhone D+R Balance application deserves further investigation as a means of assessing postural sway and may provide an alternative to current dynamic posturography systems.

The Fukuda stepping test is commonly used to assess peripheral vestibular function. It has, however, been suggested that its maximal sensitivity and specificity are 70 per cent and 50 per cent, respectively. This study was undertaken to evaluate environmental factors that may influence the reliability of this assessment and hence to ‘sharpen’ its use in a clinical setting.

Forty-four participants aged between 20 and 43 years were asked to perform the Fukuda stepping test in both a standard clinic room and a soundproofed room under the following conditions in a randomised order: on the floor versus on foam; with and without a sound-localising source; and with and without ear defenders.

Significant differences in the extent of rotation were found when comparing the results obtained in several settings, including standing on the floor in a standard room versus a soundproofed room (p = 0.036), and standing on foam in a standard room versus a soundproofed room (p = 0.015).

Our results suggest that certain alterations to the test environment may improve the sensitivity of this clinical examination.

Peripheral vestibular function is commonly assessed using the Unterberger test. Patients are asked to march on the spot and their extent of rotation is recorded. The sensitivity of this test depends on an assessor accurately estimating the degree of rotation. This study therefore aimed to compare observer estimates with a smartphone application (DplusR Balance) that accurately records rotation.

Twenty-five participants were asked to estimate the degree of rotation in 10 successive Unterberger tests performed by a volunteer.

The average difference between estimated and application recorded extent of rotation was 30°.

Assessors poorly estimate the degree of rotation in this clinical test, to an extent sufficient to affect clinical interpretation and diagnosis. We recommend the use of this application or alternative methods to record the degree of rotation in patients.

Ototoxicity caused by medication can lead to debilitating symptoms such as dizziness, vertigo and postural instability. There is no current ‘gold standard’ treatment available.

A 79-year-old male, with bilateral loss of vestibular function caused by gentamicin toxicity after surgery for prosthetic valve endocarditis, complained of dizziness, difficulty in walking and an increased risk of falling. Physical examination showed a positive head thrust test suggesting bilateral loss of vestibular function.

The patient underwent a specific motion-based virtual reality enhanced protocol for peripheral vestibular disease. He showed a great improvement, with a 50 per cent reduction in his Dizziness Handicap Inventory score.

Computer-aided rehabilitation programmes might represent an important advance in gait and posture training.

To create a ‘one-stop’ clinic in which assessment, diagnosis, treatment and therapies for most patients presenting with balance and dizziness disorders are delivered simultaneously.

Patients triaged via referral letters were selected to attend the balance clinic, which is led by specialist balance physiotherapists. Patients were seen by an audiologist, and a ‘balance’ ENT consultant was available for joint consultations when required. Further details of the clinic set up are discussed.

Over an 18-month period, 200 new ‘dizzy’ patients attended the clinic. Benign paroxysmal positional vertigo and labyrinthitis were the commonest diagnoses. Fifty per cent of all patients were discharged after a single clinic visit. Questionnaires showed that patient satisfaction was high.

The physiotherapy-led balance clinic has reduced patient waiting times to be seen, has a high level of patient satisfaction and is economically beneficial.

To determine the long-term efficacy of a fixed-dose intratympanic gentamicin treatment regime in controlling unilateral Ménière's disease.

Pfleiderer (1998) published two-year follow-up results for a series of 16 patients treated with a 4-day, 12-dose intratympanic gentamicin regime for unilateral Ménière's disease that was refractory to medical treatment. In 2010, a long-term telephone follow up (mean 17 years and 3 months) of this same cohort was conducted to determine long-term vertigo control. Of the 16 patients, 13 were eligible for the long-term follow up.

At 2 years' follow up, all 16 patients experienced substantial control of vertigo, with complete control achieved in 87 per cent of cases. At the long-term follow up, 9 of the 13 eligible patients were contactable, and all reported complete control of vertigo.

Fixed-dose intratympanic gentamicin controlled symptomatic unilateral Ménière's disease in both the short and long term.